Instrument No. 18 of 2005   Revocation of Statements of Principles concerning   IMPOTENCE   and Determination of Statement of Principles concerning   ERECTILE DYSFUNCTION     for the purposes of the   Veterans’ Entitlements Act 1986 and Military Rehabilitation and Compensation Act 2004   1.         The Repatriation Medical Authority under subsection 196B(3) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):   (a)               revokes Instrument No. 98 of 1996, as amended by Instrument No. 17 of 2002, concerning impotence; and (b)              determines in their place the following Statement of Principles.   Kind of injury, disease or death 2.         (a)        This Statement of Principles is about erectile dysfunction and death from erectile dysfunction.   (b)              For the purposes of this Statement of Principles, “erectile dysfunction” means persistent or recurrent inability to develop or maintain an erection adequate for sexual intercourse. This definition excludes transient failure of erection due to fatigue, situational anxiety, alcohol or drugs.   Basis for determining the factors 3.         On the sound medical-scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that erectile dysfunction and death from erectile dysfunction can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the Military Rehabilitation and Compensation Act 2004 (the MRCA).   Factors that must be related to service 4.         Subject to clause 6, at least one of the factors set out in clause 5 must be related to the relevant service rendered by the person.   Factors 5.         The factor that must exist before it can be said that, on the balance of probabilities, erectile dysfunction or death from erectile dysfunction is connected with the circumstances of a person’s relevant service is:   (a)               having a clinically significant mood disorder with depressive features or a clinically significant anxiety disorder at the time of the clinical onset of erectile dysfunction; or   (b)       smoking at least fifteen pack years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of erectile dysfunction; or   (c)              the presence of hypertension at the time of the clinical onset of erectile dysfunction; or   (d)              being obese at the time of the clinical onset of erectile dysfunction; or   (e)              having ischaemic heart disease at the time of the clinical onset of erectile dysfunction; or   (f)               having atherosclerotic peripheral vascular disease at the time of the clinical onset of erectile dysfunction; or   (g)              having non-aneurysmal aortic atherosclerotic disease at the time of the clinical onset of erectile dysfunction; or   (h)              having diabetes mellitus at the time of the clinical onset of erectile dysfunction; or   (i)                undergoing a course of therapeutic radiation to the lower abdomen, pelvis, penis or perineal region within the fifteen years immediately before the clinical onset of erectile dysfunction; or   (j)                having a specified endocrinological disorder at the time of the clinical onset of erectile dysfunction; or   (k)              experiencing blunt or penetrating trauma to the external genitals, perineum or pelvis, including surgical trauma, within the ninety days immediately before the clinical onset of erectile dysfunction; or   (l)                experiencing a traumatic injury, including surgical trauma, that results in acute and permanent neurological sequelae involving the brain, spinal cord or cauda equina, within the ninety days before the clinical onset of erectile dysfunction; or   (m)            having a specified neurological disorder at the time of the clinical onset of erectile dysfunction; or   (n)              having cirrhosis of the liver at the time of the clinical onset of erectile dysfunction; or   (o)              having chronic renal failure at the time of the clinical onset of erectile dysfunction; or   (p)              having alcohol dependence or alcohol abuse at the time of the clinical onset of erectile dysfunction; or   (q)              being treated with a drug from a class of drug in Specified List 1, for a condition for which the drug cannot be ceased or substituted, at the time of the clinical onset of erectile dysfunction; or   (r)               being treated with a drug in Specified List 2, for a condition for which the drug cannot be ceased or substituted, at the time of the clinical onset of erectile dysfunction; or     (s)               having low-flow priapism for a continuous period of at least four hours immediately before the clinical onset of erectile dysfunction; or   (t)                having Peyronie’s disease before the clinical onset of erectile dysfunction; or   (u)              having haemochromatosis before the clinical onset of erectile dysfunction; or   (v)               having a malignant neoplasm of the reproductive organs at the time of the clinical onset of erectile dysfunction; or   (w)             having a clinically significant mood disorder with depressive features or a clinically significant anxiety disorder at the time of the clinical worsening of erectile dysfunction; or   (x)              smoking at least fifteen pack years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of erectile dysfunction; or   (y)              the presence of hypertension at the time of the clinical worsening of erectile dysfunction; or   (z)       being obese at the time of the clinical worsening of erectile dysfunction; or   (za)      having ischaemic heart disease at the time of the clinical worsening of erectile dysfunction; or   (zb)     having atherosclerotic peripheral vascular disease at the time of the clinical worsening of erectile dysfunction; or   (zc)     having non-aneurysmal aortic atherosclerotic disease at the time of the clinical worsening of erectile dysfunction; or   (zd)     having diabetes mellitus at the time of the clinical worsening of erectile dysfunction; or   (ze)     undergoing a course of therapeutic radiation to the lower abdomen, pelvis, penis or perineal region within the fifteen years immediately before the clinical worsening of erectile dysfunction; or   (zf)      having a specified endocrinological disorder at the time of the clinical worsening of erectile dysfunction; or   (zg)     experiencing blunt or penetrating trauma to the external genitals, perineum or pelvis, including surgical trauma, within the ninety days immediately before the clinical worsening of erectile dysfunction; or   (zh)     experiencing a traumatic injury, including surgical trauma, that results in acute and permanent neurological sequelae involving the brain, spinal cord or cauda equina, within the ninety days before the clinical worsening of erectile dysfunction; or   (zi)      having a specified neurological disorder at the time of the clinical worsening of erectile dysfunction; or   (zj)      having cirrhosis of the liver at the time of the clinical worsening of erectile dysfunction; or   (zk)     having chronic renal failure at the time of the clinical worsening of erectile dysfunction; or   (zl)      having alcohol dependence or alcohol abuse at the time of the clinical worsening of erectile dysfunction; or   (zm)    being treated with a drug from a class of drug in Specified List 1, for a condition for which the drug cannot be ceased or substituted, at the time of the clinical worsening of erectile dysfunction; or   (zn)     being treated with a drug in Specified List 2, for a condition for which the drug cannot be ceased or substituted, at the time of the clinical worsening of erectile dysfunction; or   (zo)     having low-flow priapism for a continuous period of at least four hours immediately before the clinical worsening of erectile dysfunction; or   (zp)     having Peyronie’s disease before the clinical worsening of erectile dysfunction; or   (zq)     having haemochromatosis before the clinical worsening of erectile dysfunction; or   (zr)      having a malignant neoplasm of the reproductive organs at the time of the clinical worsening of erectile dysfunction; or   (zs)      inability to obtain appropriate clinical management for erectile dysfunction.   Factors that apply only to material contribution or aggravation 6.         Paragraphs 5(w) to 5(zs) apply only to material contribution to, or aggravation of, erectile dysfunction where the person’s erectile dysfunction was suffered or contracted before or during (but not arising out of) the person’s relevant service.   Inclusion of Statements of Principles 7.                  In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles.   Other definitions 8.                  For the purposes of this Statement of Principles:   “ a class of drug in Specified List 1” means: (a)               histamine2 receptor antagonists, including cimetidine and ranitidine; (b)              antihypertensive agents, including beta-blockers, central acting sympatholytics, angiotensin converting enzyme inhibitors and calcium channel blockers but excluding alpha-blockers; (c)              antiandrogens, including finasteride and cyproterone acetate; (d)              steroid or sex hormones, including oestrogen, progesterone, corticosteroids, anabolic steroids and testosterone; (e)              diuretics, including loop diuretics, thiazides and spironolactone; (f)               lipid lowering drugs, including statins and fibrates; (g)              antiepileptics, including barbiturates, carbemazepine, phenytoin, sodium valproate; (h)              anticholinergics, including atropine, scopolamine and cogentin; (i)                antidepressants, including tricyclic antidepressants, monoamine oxidase inhibitors and selective serotonin reuptake inhibitors; (j)                cytotoxic agents, including alkylating agents, antimetabolites, vinca alkaloids, cisplatin, etoposide and bleomycin; (k)              antipsychotics, including phenothiazines, butyrophenones, risperidone and clozapine; (l)                tranquillizers, including benzodiazepines; (m)            antiemetics, including prochlorperazine, metoclopramide and domperidone; or (n)              narcotics;   “a course of therapeutic radiation” means one or more fractions (treatment portions) of ionising radiation administered with the aim of achieving palliation or cure with gamma rays, x-rays, alpha particles or beta particles;   “a specified endocrinological disorder” means a disorder of the endocrine system which can result in sexual dysfunction, and includes: (a)       Cushing’s syndrome; (b)              acromegaly; (c)              hypogonadism; (d)              testicular hypofunction; (e)              hypogonadotrophic hypogonadism; (f)               hyperthyroidism; (g)              hypothyroidism; (h)              hyperprolactinaemia; (i)               pituitary gland adenoma; (j)               pituitary or hypothalamic dysfunction; or (k)              panhypopituitarism;   “a specified neurological disorder” means one of the following: (a)       a lesion of the temporal lobe; (b)              epilepsy; (c)              multiple sclerosis; (d)              peripheral autonomic neuropathy; (e)              Parkinson’s disease or secondary parkinsonism; (f)               Guillain-Barre syndrome; (g)              cerebrovascular accident; or (h)              compression, neoplasm, infection or inflammation of the brain, spinal cord, thoracolumbar nerve roots or cauda equina;   “being obese” means an increase in body weight by way of fat accumulation which results in a Body Mass Index (BMI) of thirty or greater. The BMI = W/H2 and where: W is the person’s weight in kilograms and H is the person’s height in metres;   “blunt or penetrating trauma” means an injury that results in pain and swelling or tenderness for at least forty-eight hours and which is of sufficient severity to warrant medical attention;   “chronic renal failure” means irreversible kidney damage which leads to impaired renal function;   “clinically significant” means sufficient to warrant ongoing management, which may involve regular visits (for example, at least monthly), to a psychiatrist, counsellor or general practitioner;   “death from erectile dysfunction” in relation to a person includes death from a terminal event or condition that was contributed to by the person’s erectile dysfunction;   “drug in Specified List 2” means: (a)               oral ketoconazole; (b)              digoxin; (c)              lithium; or (d)              any other drug reported in a peer reviewed medical or scientific publication to cause erectile dysfunction;   “low-flow priapism” means persistent abnormal erection of the penis caused by corporeal veno-occlusion;   “malignant neoplasm of the reproductive organs” means: (a)               malignant neoplasm of the penis or other male genital organs; or (b)              malignant neoplasm of the testis and paratesticular tissues; or (c)              malignant neoplasm of the prostate;   “pack years of cigarettes, or the equivalent thereof in other tobacco products” means a calculation of consumption where one pack year of cigarettes equals twenty tailor made cigarettes per day for a period of one calendar year, or 7300 cigarettes. One tailor made cigarette approximates one gram of tobacco or one gram of cigar or pipe tobacco by weight. One pack year of tailor made cigarettes equates to 7300 cigarettes, or 7.3kg of smoking tobacco by weight. Tobacco products means either cigarettes, pipe tobacco or cigars smoked, alone or in any combination;   “Peyronie’s disease” means induration of the corpora cavernosa of the penis, characterised by a circumscribed, firm, painless plaque or band, usually situated on the dorsum of the penis;   “relevant service” means: (a)       eligible war service (other than operational service) under the VEA; or (b)       defence service (other than hazardous service) under the VEA; or (c)              peacetime service under the MRCA;   “terminal event” means the proximate or ultimate cause of death and includes: (a)       pneumonia; (b)       respiratory failure; (c)       cardiac arrest; (d)       circulatory failure; or (e)              cessation of brain function;   Application 9.         This Instrument applies to all matters to which section 120B of the VEA or section 339 of the MRCA applies.   Date of effect 10.       This Instrument takes effect from 22 June 2005.   Dated this     eighth     day of                  June          2005     The Common Seal of the                              ) Repatriation Medical Authority                   ) was affixed to this instrument                      ) in the presence of:                                        )   KEN DONALD CHAIRPERSON